Quality adjusted life years in the time of COVID-19

The quality adjusted life year (QALY) as a basis of valuing additional expenditure on health is widely accepted. Although early in the COVID-19 pandemic, several commentators called for a similar approach in resolving trade-offs between economic activity and reducing the burden of COVID-19, this has not occurred. The value of a QALY has not been used to deny all intervention, as the rule of rescue attests. Further, while there was no other way of managing the pandemic, there were other means available to mitigate the economic losses. Now that vaccine programs have commenced in several countries, it is interesting to consider whether economic evaluation should now be applied. However, the recognised complexities of the evaluation of vaccines, plus the challenge of measuring opportunity costs in the face of an economic recession and the severity of the consequences of an outbreak even though the probability of transmission is exceedingly low, mean its use will be restricted. COVID-19 has changed everything, even the way we should think about economic evaluation

Are the true impacts of adverse events considered in economic models of antineoplastic drugs? a systematic review

Background: Antineoplastic drugs for cancer are often associated with adverse events, which influence patients' physical health, quality of life and survival. However, the modelling of adverse events in cost-effectiveness analyses of antineoplastic drugs has not been examined. Aims: This article reviews published economic evaluations that include a calculated cost for adverse events of antineoplastic drugs. The aim is to identify how existing models manage four issues specific to antineoplastic drug adverse events: the selection of adverse events for inclusion in models, the influence of dose modifications on drug quantity and survival outcomes, the influence of adverse events on quality of life and the consideration of multiple simultaneous or recurring adverse events. Methods: A systematic literature search was conducted using MESH headings and key words in multiple electronic databases, covering the years 1999-2009. Inclusion criteria for eligibility were papers covering a population of adults with solid tumour cancers, the inclusion of at least one adverse event and the resource use and/or costs of adverse event treatment. Results: From 4,985 citations, 26 eligible articles were identified. Studies were generally of moderate quality and addressed a range of cancers and treatment types. While the four issues specific to antineoplastic drug adverse events were addressed by some studies, no study addressed all of the issues in the same model. Conclusion: This review indicates that current modelling assumptions may restrict our understanding of the true impact of adverse events on cost effectiveness of antineoplastic drugs. This understanding could be improved through consideration of the selection of adverse events, dose modifications, multiple events and quality of life in cost-effectiveness studies. © 2013 Springer International Publishing Switzerland

Understanding the factors influencing doctors' intentions to report patient safety concerns: a qualitative study

OBJECTIVES: To investigate doctors' intentions to raise a patient safety concern by applying the socio-psychological model 'Theory of Planned Behaviour'. DESIGN: Qualitative semi-structured focus groups and interviews. SETTING: Training venues across England (North West, South East and South West). PARTICIPANTS: Sampling was purposeful to include doctors from differing backgrounds and grades. MAIN OUTCOME MEASURES: Perceptions of raising a patient safety concern. RESULTS: While raising a concern was considered an appropriate professional behaviour, there were multiple barriers to raising a concern, which could be explained by the Theory of Planned Behaviour. Negative attitudes operated due to a fear of the consequences, such as becoming professionally isolated. Disapproval for raising a concern was encountered at an interpersonal and organisational level. Organisational constraints of workload and culture significantly undermined the raising of a concern. Responses about concerns were often side-lined or not taken seriously, leading to demotivation to report. This was reinforced by high-profile cases in the media and the negative treatment of whistle-blowers. While regulator guidance acted as an enabler to justify raising a concern, doctors felt disempowered to raise a concern about people in positions of greater power, and ceased to report concerns due to a perceived lack of action about concerns raised previously. CONCLUSIONS: Intentions to raise a concern were complex and highly contextual. The Theory of Planned Behaviour is a useful model to aid understanding of the factors which influence the decision to raise a concern. Results point to implications for policymakers, including the need to publicise positive stories of whistle-blowers and providing greater support to doctors

Breaking up is hard to do: Why disinvestment in medical technology is harder than investment

Healthcare technology is a two-edged sword - it offers new and better treatment to a wider range of people and, at the same time, is a major driver of increasing costs in health systems. Many countries have developed sophisticated systems of health technology assessment (HTA) to inform decisions about new investments in new healthcare interventions. In this paper, we question whether HTA is also the appropriate framework for guiding or informing disinvestment decisions. In exploring the issues related to disinvestment, we first discuss the various HTA frameworks which have been suggested as a means of encouraging or facilitating disinvestment. We then describe available means of identifying candidates for disinvestment (comparative effectiveness research, clinical practice variations, clinical practice guidelines) and for implementing the disinvestment process (program budgeting and marginal analysis (PBMA) and related techniques). In considering the possible reasons for the lack of progress in active disinvestment, we suggest that HTA is not the right framework as disinvestment involves a different decision making context. The key to disinvestment is not just what to stop doing but how to make it happen - that is, decision makers need to be aware of funding disincentives. What is known about this topic? Disinvestment is an increasingly popular topic amongst academics and policy makers. Most discussions focus on the need to increase disinvestment as a corollary of investment, the lack of overt disinvestment decisions and the use of a framework based on health technology assessment (HTA) to implement disinvestment. What does this paper add? This paper focusses on the difficulties associated with deciding which technologies to disinvest in, and the problems in using an HTA framework to make such decisions, when disinvestment involves a different decision making context from that of investment. What are the implications for practitioners? The key to disinvestment is not just what to stop doing but how to implement such decisions. Making it happen means being aware of funding disincentives. © 2012 AHHA

Does the structure of the medical consultation align with an educational model of clinical communication? A study of physicians’ consultations from a postgraduate examination

OBJECTIVE: This study examined whether the structure of consultations in which physicians were tasked with sharing information corresponded to the chronological stages proposed by an established educational model of clinical communication. METHOD: Seventy six simulated consultations from a postgraduate examination for general medical hospital physicians were transcribed verbatim and converted into diagrams showing consultation structure. All doctor-patient/relative talk was allocated into six phases: Initiating, Gathering information, Summary, Explanation, Planning and Closing, using the ‘communication process skills’ from the Calgary-Cambridge Guide to the Medical Interview. RESULTS: The majority of consultations included four or five of the expected phases, with most talk (41-92%) in Explanation and Planning. There was no discernible consistency of structure across the consultations or in consultations from the same scenario. Consultations varied in the presence, sequential order, size, location and reappearance of phases. CONCLUSIONS: The structure of consultations in this standardised setting bore little resemblance to the chronological order of phases predicted by an educational model. PRACTICE IMPLICATIONS: Educational guidance and interventions to support patients in preparing for consultations need to take account of doctors’ behaviour in practice. Assumptions about the organisation of medical consultations should be queried in the absence of an evidence base

The impact of childhood language difficulties on healthcare costs from 4 to 13 years: Australian longitudinal study

© 2016 The Speech Pathology Association of Australia Limited Published by Taylor & Francis. Purpose: This study investigated the relationship between children’s language difficulties and health care costs using the 2004–2012 Longitudinal Study of Australian Children (LSAC). Method: Language difficulties were defined as scores ≤1.25SD below the standardised mean on measures of directly assessed receptive vocabulary (4–9 years) and teacher-reported language and literacy (10–13 years). Participant data were individually linked to administrative data, which were sourced from Australia’s universal subsidised healthcare scheme (Medicare). Result: It was found that healthcare costs over each 2-year age band were higher for children with language difficulties than without in the 4–5-year-age bracket (mean difference = AU$357, 95$59, $659), in the 6–7-year-age bracket (mean difference = AU$602, 95%CI $136,$1068) and in the 10–11-year-age bracket (mean difference = AU$504, 95$153, $854). Out-of-pocket costs, that is the portion of healthcare costs paid for by the family, were also higher for children with than without language difficulties in the 4–5-year-age bracket (mean difference = AU$123, 95%CI $46,$199), in the 6–7-year-age bracket (mean difference = AU$176, 95$74,278) and in the 10–11-year-age bracket (mean difference = AU$79, 95$6, $152). Medical services accounted for 97% of total healthcare cost differences. Conclusion: Overall the findings from this study suggest that language difficulties are associated with increased healthcare costs at key developmental milestones, notably early childhood and as a child approaches the teenage years

Preferences for new and existing contraceptive products

New contraceptive methods provide greater choice in terms of effectiveness, management of side-effects, convenience and frequency of administration and flexibility, but make the decisions about contraception more complex. There are limited data on the factors that determine women's choices among these alternatives, to inform providers about the factors which are most important to women, or to predict uptake of new products. This paper reports on a choice experiment designed to elicit women's preferences in relation to prescribed contraception and to forecast the impact of the introduction of two new products into the Australian market. A generalised multinomial logit model is estimated and used in the simulation exercise. The model forecasts that the hormonal patch would be well received among women, achieving a greater market share than current non-pill products, but the vaginal ring would have limited appeal. Copyright © 2011 John Wiley & Sons, Ltd

Perceived causes of differential attainment in UK postgraduate medical training: a national qualitative study

Objectives: Explore trainee doctors’ experiences of postgraduate training and perceptions of fairness in relation to ethnicity and country of primary medical qualification. Design: Qualitative semistructured focus group and interview study. Setting: Postgraduate training in England (London, Yorkshire and Humber, Kent Surrey and Sussex) and Wales. Participants: 137 participants (96 trainees, 41 trainers) were purposively sampled from a framework comprising: doctors from all stages of training in general practice, medicine, obstetrics and gynaecology, psychiatry, radiology, surgery or foundation, in 4 geographical areas, from white and black and minority ethnic (BME) backgrounds, who qualified in the UK and abroad. Results: Most trainees described difficult experiences, but BME UK graduates (UKGs) and international medical graduates (IMGs) could face additional difficulties that affected their learning and performance. Relationships with senior doctors were crucial to learning but bias was perceived to make these relationships more problematic for BME UKGs and IMGs. IMGs also had to deal with cultural differences and lack of trust from seniors, often looking to IMG peers for support instead. Workplace-based assessment and recruitment were considered vulnerable to bias whereas examinations were typically considered more rigorous. In a system where success in recruitment and assessments determines where in the country you can get a job, and where work–life balance is often poor, UK BME and international graduates in our sample were more likely to face separation from family and support outside of work, and reported more stress, anxiety or burnout that hindered their learning and performance. A culture in which difficulties are a sign of weakness made seeking support and additional training stigmatising. Conclusions: BME UKGs and IMGs can face additional difficulties in training which may impede learning and performance. Non-stigmatising interventions should focus on trainee–trainer relationships at work and organisational changes to improve trainees’ ability to seek social support outside work